- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $82.27 / $82.27 / $134.19
| Facility | 26 | $82.27 | $82.27 | $134.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.88 / $416.65 / $536.39
| Professional | | $253.88 | $416.65 | $536.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.27 / $162.47 / $223.80
| Professional | | $107.27 | $162.47 | $223.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.37 / $286.32 / $436.10
| Professional | | $83.37 | $286.32 | $436.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.63 / $389.89 / $735.16
| Professional | | $196.63 | $389.89 | $735.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.73 / $346.30 / $629.74
| Professional | | $231.73 | $346.30 | $629.74 |